Unique issues arise when we run outpatient clinics on Sundays. Usually Sundays are holidays for most working people, and they prefer to come to see the doctor. Working sons and daughters also find it convenient to accompany their elderly parents to the clinic. Public transport is relatively free in rural areas on Sundays. Those who work for weekly wages receive it on Saturday and they have dispensable money in hand to bring to the clinic. However, Sundays are also the only day of the week when working people catch up with personal household chores like washing clothes, cleaning the house etc., the day of the most elaborate meat-based meal in the afternoon and the day to catch up on an afternoon siesta or television, friends or family time. So having come to the clinic, everyone wants to leave as soon as possible to catch up with all this. So, Sunday clinics are a recipe for crowds, impatient and irritable.
Yesterday was no exception! When I entered the clinic at 8.40 AM, there was already a crowd waiting outside for me. I had a quick breakfast of super-soft idlies and flavorful coconut chutney, which you can get only in rustic rural areas, and started clinic at 9.02 AM. A young man who was waiting was irritable and kept peeping into the large wall clock placed in the waiting area of the clinic. He gave me a look as though the 2-minute delay in start time was an unpardonable sin.
Another interesting thing about Sunday clinics is that the most complicated patients end up in the clinic on that day. I had some patients who had come for routine prescription refill for their long-term health conditions like diabetes and high blood pressure. It was easy to address the routine treatment of these patients quickly and efficiently. However, there was a man with a lung condition called emphysema, which made him extremely breathless, and he was very sick. He had come with a thick folder of various treatments taken over the years and several chest X rays and CT scan images for me to see. There was no way I could have seen that patient in less than 20 minutes. There was a man with tuberculosis of the lung which was not responding to standard treatment. I had to discuss with the state TB officers over phone to refer him appropriately for higher treatment, and that consumed a significant part of my time. A man with nodules over his skin, ulcers in his genitals and mouth, had come for detailed evaluation and treatment. I had vague recollection of a rare syndrome which presents like this, called Behcet’s syndrome and had to quickly read it up to understand it better, again consuming significant time.
Some of these patients required only a couple of minutes to see and treat, while for certain others I took 15-20 minutes to understand and initiate treatment. Even before I could realize the passage of time and look up to see the clock on the wall, it was 11.45 AM. At that time a middle-aged man walked into the clinic and took his seat beside me. He was a tall man, 6 feet in height, well built, wearing a dark blue collared T Shirt and a white dhoti. I have seen him a couple of times in the clinic, but could not recollect his name and details immediately.
“What sir, looks like you did not recognize me. I am Soandso’s husband. How are you?” he said. Soandso is a community health worker in our organization and had brought him for treatment a few months ago. We had diagnosed him to have diabetes and had started him on tablets. I was able to recollect after he said her name. I acknowledged him and greeted him back. He had come for his prescription refill. I went through the standard questions that I ask of a person with diabetes regarding their diet, exercise, foot care, and symptoms of any worsening of the sugar levels. Then I wrote down the prescription and that was supposed to be the end of the clinical encounter. It was uncomplicated and it hadn’t taken more than 5 mins. As he gathered his prescription to leave, he said, “Sir, please don’t mistake me for telling this. But I think you are spending way too much time with patients. So, the queue gets backed up outside and we were waiting for a long time. You must see patients faster and send them off.”
This is not the first time I am hearing this comment from patients. So, I was not surprised. I smiled at him and nodded. Nowadays I don’t respond to this comment. But Soandso’s husband was not happy with my silence. He went on, “I was waiting outside and the girl sitting next to me fainted. She was very sick. So, I allowed her to go ahead of me. Didn’t you see the girl who came before me?”
I remembered that girl. She had come with painful menstrual cramps, and I had treated her with painkillers and sent her just before this man came in. I nodded and checked the clock, hoping that he would get the clue and walk out. But no, he continued, “I was broad minded to sacrifice my spot in the queue to that girl because she was sick. But you can go out and see others are not as broad minded as me. The crowd is suffering. So, you should see patients faster.” When I heard this, I laughed inside but did not show it out. The narrative had slowly started switching from social conscience to self-aggrandizement. I still did not say anything. I stood up, indicating that he had to leave. But Soandso’s husband hadn’t gotten the clue. He stood up too and said, “Sir, it is all about effective time management. If the patient has something like a simple cough and cold, you should see them and send them off soon. But someone with more severe conditions, you can take more time.” It started sounding like a lecture now. I was starting to get irritated. Not only that, but I had also run out of my polite cues to make him leave. I walked towards the door and called the next patient and turned to face Soandso’s husband. I said, “Thank you very much. I will remember whatever you said. Now I think I will see the next patient.” With that he walked out of the room, and I started seeing the next patient.
Just to the left of my consultation room is the door to the pharmacy. Even as I am sitting and seeing patients, it is easy for me to call out to the staff nurse dispensing medicines in the pharmacy with any questions or instructions that I may have. Also, it is quite easy to hear conversations between patients and the staff nurse through the door to the pharmacy. As I finished seeing the next patient who had come for a hypertension prescription refill, I heard the unmistakable deep gurgling voice of Soandso’s husband from the pharmacy door. “Sister, doctor got very angry with me. There was no need to get angry. I was only telling him how time management is important. I was speaking for the benefit of those waiting outside. But doctor got angry and sent me out.” I did not pay much attention to what he said as there was no time for it. Patients were coming in as a steady stream.
In the evening as the day came to an end and I was reflecting on the proceedings of the day, Soandso’s husband and his unsolicited advice came to my mind. He took it upon himself to be the voice of the vulnerable and addressed the issue of prolonged waiting times. He had not considered the fact that there were two sides to the problem. Prolonged waiting times is the patient’s side of the problem, and relentless inflow of patients and cognitive fatigue is the physicians side. While Soandso’s husband wanted ‘efficient’ and fast disposal of all patients, he himself did not mind overstaying his welcome and giving me unsolicited advice. When we are waiting for the consultation the time seems way longer than when we are inside the consultation chamber with the clinician. This cognitive bias distorts our perception of time and leads to the dissatisfaction with waiting times. Soandso’s husband’s advice, though well intentioned, was not necessary because we had ourselves thought about it, discussed it extensively, attempted several strategies and have had short successes at various points, but sustained relapse to the chaotic delays in waiting for consultation. We don’t have a workable solution to the problem of reducing the inordinate waiting times for patients in our clinic. We are still looking! Meanwhile the husbands of the various Soandsos will continue taking our time to lecture us on effective time management!
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